Organization
GOLDEN TRIANGLE PATHOLOGY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHN P FULLENWIDER M.D. (OWNER)
(800) 362-0858
Entity
Organization
Contact information
Practice address
2520 5TH ST N, COLUMBUS, MS 39705-2008
(800) 362-0858
(662) 534-7188
Mailing address
PO BOX 2906, OXFORD, MS 38655-2925
(800) 362-0858
(662) 534-7188
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02622338
—
MS
01
—
DS3144
RAILROAD MEDICARE
—
Enumeration date
10/27/2011
Last updated
11/07/2014
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